Capturing the Essence of the Wound Evaluation
May 12, 2008
Pam Unger PT, CWS; Caroline Fife, MD, FAAFP, CWS; and Dot Weir, RN, CWON, CWS
ocumentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention.
Wound care is usually best performed by a team of experts. Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice.
The examination phase of a wound consultation is assumed to be the most important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors.
Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors. In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation.
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